Kids save lives: Who should train schoolchildren in resuscitation? A systematic review

Aim CPR training for schoolchildren to increase bystander CPR-rates is widely applied. HCPs are regarded as the instructor gold standard, but using non-HCP instructors (e.g., peer-tutors, schoolteachers, medical students) challenges that. This systematic review assesses whether cardiopulmonary resuscitation (CPR) training for children led by peer-tutors, schoolteachers, or medical students results in different learning outcomes to training by health-care professionals (HCPs). Methods We searched studies that compared CPR training for schoolchildren (population) delivered by peer-tutors, schoolteachers, or medical students (intervention), with training led by HCPs (comparison), assessing student knowledge, skills, willingness and/or confidence to perform CPR (outcome). We included randomized and non-randomized controlled trials (study design). Medline, Embase, Psychinfo, Cinahl, Cochrane, Scopus, Web of Science, and Eric were searched from inception until December 23rd, 2023 (timeframe). Two independent reviewers performed title, abstract, full text screening, bias assessment, and grading of certainty of evidence. We followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) guidelines, and registered the review with PROSPERO. Results Of 9′092 studies identified, 14 were included. Comparison of intervention groups to HCP-led training showed similar overall results (knowledge, skills, self-confidence). Superior results for HCP training were only reported for ‘ventilation volume’, while schoolteachers and medical students achieved superior knowledge transfer. A meta-analysis was possible for ‘compression depth’ between peer-tutors and HCPs showing no significant differences. Certainty of evidence was ‘low’ to ‘very low’. Conclusion This systematic review of CPR training for school children revealed that peer-tutors, schoolteachers and medical students achieve similar educational outcomes compared to those of HCPs. Non-HCPs training schoolchildren is an appropriate cost-efficient alternative and easy to implement in school curricula.


Introduction
3][4][5][6][7] Layperson CPR-training is associated with increased cardiac arrest recognition 8 and higher likelihood of initiating CPR before EMS-arrival. 7,9One way to achieve wide-spread CPR-training independent of socio-economic factors is to train schoolchildren. 10The 'Kids-Save-Lives' programme has been endorsed by the WHO since 2012 11 and was highlighted in a statement by the 'International Liaison Committee on Resuscitation' (ILCOR) in 2023. 12,13Overall, regular CPR training for schoolchildren has been shown to generate and consolidate knowledge and skills in all age groups. 12hile only a few countries have implemented mandatory training of CPR for schoolchildren, most of these programmes have been established on a voluntarily basis.These programmes suffer mainly from two often-quoted barriers: (a) difficulties integrating the programmes into school curricula and scheduling problems, and (b) limitations of resources, namely expenses for manikins and for instructors. 14,15Certified health care professionals (HCP) are considered the 'gold standard' for CPR instructors, but they pose scheduling challenges within a school curriculum and produce extra costs.7][18] .The ILCOR Scientific Statement suggests using schoolteachers for training, however, this suggestion has not been based upon a rigorous systematic review. 12Therefore, the aim of this study was to systematically assess the existing literature comparing the effect of HCP-led CPR training to CPR training by medical students, schoolteachers, or peer-tutors ('alternative instructors').We did not address other alternatives to HCP-led training (such as self-learning) to keep the focus on the question 'who should instruct'.

Methods
This systematic review was registered at the Prospective Registry for Systematic Reviews (PROSPERO CRD42024491922) and followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA). 19e organized the research question according to the PICOST format (population, intervention, comparator, outcome, study design, timeframe).

Do schoolchildren (population),
receiving CPR-training by peer-tutor, schoolteacher, or medical students (intervention) compared to those receiving CPR-training led by HCPs (comparator) show equivalent educational outcomes (knowledge, skills, willingness and/or confidence to perform CPR) after the CPR-training (outcome)?Peer-reviewed randomized controlled trials (RCTs) and nonrandomized controlled studies (non-RCTs) were eligible (study design).Publications from inception of each database to the search date (23.12.2023) were included.No language limitations were set as long as an English abstract was available (timeframe).

Definitions
As 'peer-tutors' we defined schoolchildren either of the same age as their 'trainees' or older.In all cases, the more precise wording would be 'near'-peers as the peers have some kind of preceding training and additional knowledge before their teaching task.'HCP instructor', was defined as any person with a professional background in health care with some kind of an instructor qualification.

Selection of eligible articles
The search strategy was generated and conducted by an information specialist of the University of Zurich (Appendix A).We searched Medline, Embase, Psychinfo, Cinahl, Cochrane, Scopus, Web of Science and Eric.Finally, the reference lists of the included studies were screened by the first author for eligible studies that might have been missed by the search strategy.The inclusion criteria were: I) CPR training of schoolchildren, II) intervention group was trained by either peer-tutors, schoolteachers or medical students and III) the control group was instructed by HCPs.Exclusion criteria were: I) children's median age >16 years, II) No control group, or control group that did not receive any training and III) Conference abstracts.For abstract screening, full text screening and the data collection processes, we used the software 'Covidence' [https://www.covidence.org].All sources were screened by the first author and one additional author independently and conflicts were solved bilaterally through open discussion.In case of remaining discrepancies, a third reviewer was involved to achieve consensus.Data were extracted into Excel [https://www.microsoft.com/]sheets and comprised training formats, characteristics of schoolchildren, instructor training, and outcomes after training, including knowledge, skills, willingness to perform CPR and self-confidence at different post-intervention time points.For papers reporting graphic output only, we approximated the results based on the graphics.
Two independent reviewers conducted the risk of bias assessment with the Cochrane's 'Risk Of Bias 2 0 (ROB2)-assessment for RCTs and the 'Risk Of Bias In Non-randomised Studies -of Interventions' (ROBIN-I) tool for non-RCTs at outcome level. 20,21Authors of this review who were authors of eligible studies were excluded from assessment.Conflicts were resolved bilaterally through open discussion.Certainty of evidence was evaluated using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) tool. 22

Synthesis methods & effect measures
We grouped the studies according to the instructors' professional backgrounds and according to post-intervention outcome time points.Outcome assessment included short-term (end-of-course), mid-term (later than end-of-course, up to 12 months), and longterm learning (>12 months).Following the 'Synthesis Without Meta-Analysis' (SWiM) reporting guidelines, we created effect direction plots showing whether the study reported significant differences between the intervention and control group. 23or pooled studies reporting the skills "chest compression rate and depth" in suitable metrics, we tested homogeneity with the Cochrane's Q test. 24When there was sufficient homogeneity, we calculated the effect size using inverse-variance random-effects models comparing standardized mean differences for continuous data and odds ratio for binary data (for studies reporting % of children passing the skills test).Due to methodological differences between study groups, it was not feasible to perform meta-analyses for the outcomes 'knowledge' or 'willingness to perform CPR' and 'confidence'.Meta-analysis was performed with SPSS (IBM, version 29.0 for Mac).Results are presented as forest plots.A confidence interval of a = 0.05 was used for both homogeneity testing and effect size calculation.

Results
The search identified 9 0 092 articles, and two additional studies were found by hand search.After removing 4 0 685 duplicates, 4 0 409 articles were included into the title and abstract screening, and 340 full texts were assessed, of which 14 eligible studies were included in the final analysis (PRISMA Flow chart Fig. 1, Study characteristics Table 1).
Five studies analysed training by peer-tutors, [25][26][27][28][29] seven by schoolteachers, [30][31][32][33][34][35][36] and three by medical students. 31,37,38One study separately assessed both schoolteacher-led and medical student-led training, and therefore the study was included in both subgroups. 314 Seven studies were RCTs, and seven were non-RCTs (prospective cohort studies).One follow-up study 35 of a previous study 30 (cohort overlap: 81.4%) was included as it provided additional data up to six years postintervention. From anoher study comparing medical students with residents and emergency physicians, 37 we only included the emer-gency physicians as HCPs.This study regarded the 'resident' group as a different competency level for training, and we wanted clear differences between intervention and control.Children in all studies included were attending secondary school (age range: 10-18 years, average of the 7 RCTs 25,29,31,33,[36][37][38] was 14.4 years, median of the 7 non-RCTs 27,28,30,32,34 was 15 years). Atend-of-courses, 1635 children had been trained by their peers (control group n = 716), 956 by their schoolteachers (control group n = 857), and 53 by medical students (control group n = 41). Tale 2 shows children included in the studies over time, whereas Supplemental Table 1 gives an overview of the durations of the training, the educational strategies used, and the instructors' training.
Knowledge and self-confidence were assessed by questionnaires.Skill-assessments was performed either by using checklists 25,28,29,[31][32][33][34] or by measuring CPR data by the manikin software (for details, see Table 1). 27,30,31,35sk of bias and certainty of evidence Risk of bias was rated from 'low' to 'some concerns' for RCTs, and 'moderate' to 'serious' for non-RCTs (Table 3.).The overall certainty of evidence was downgraded to 'low' or 'very low' due to risk of bias, inconsistency, and imprecision (supplemental Table 2).

Peer-tutors compared to training led by HCP (n = 5) (Table 4A)
Four studies assessed overall skills at short-term 28,29 , mid-term 28 , and long-term, 27 showing no significant differences between peerled and expert led groups.However, one study reported significantly inferior outcomes for peer-led training (short-and mid-term assess- ments) for the parameters 'check response and breathing', 'call EMS', 'compression depth' and 'compression recoil'. 28l four studies reported the assessment of chest compression rate and depth at the end-of-course as dichotomous data (% children    Call EMS failing or passing the test). 28,29One study 27 reported the percentage of children fulfilling ERC guideline recommendations, which was rated as 'pass'.Homogeneity testing for compression rate showed significant heterogeneity (Q = 8.65, df = 3, p-value = 0.03).Data for compression depth showed sufficient homogeneity to calculate the effect size (Q = 0.45, df = 3, p-value = 0.93) which revealed an overall effect of z = À0.77(p-value = 0.44).Forest plots are depicted in Fig. 2. Due to the small number of studies included in the metanalysis we did not perform a formal assessment of publication bias. 40nowledge and willingness to perform CPR was equivalent for those taught by peer-tutors and by HCPs for short-28 to midterm. 26,28hoolteacher-led training compared to training by HCPs (n = 7) (Table 4B) 3][34] Only 'ventilation volume' was lower for training by schoolteachers after 2 years in two studies. 30,35However, 'call EMS', 'compression depth', 'compression rate', and 'ventilation rate' was found better after schoolteacher training. 30,32,33,35As 'compression depth' and 'compression rate' were reported with heterogenous outcomes (pass/fail, % correct, performance scores, and definite measurements), a meta-analysis did not appear reasonable.We did not consider further methods to adjust for the inconsistencies between studies.
Schoolteacher training yielded equivalent results to HCPs in three of the five studies for knowledge, willingness to perform CPR and confidence, 30,32,34 but the other two studies showed HCPs achieved superior results. 35,36dical students compared to HCP-led training (n = 3) (Table 4C) Results of the overall skills assessment were found to be better after training by medical students than by HCPs, for short- 31 and midterm. 31,37Regarding specific skills, the studies reported equivalence for early all skills, except for 'use of defibrillators,' where the medical students achieved better results than HCPs.Transfer of knowledge for mid- 37,38 and long-term 38 was more effective when schoolchildren were instructed by medical students.Selfconfidence was reported as equivalent.

Peer-tutors
The studies included reported that peer teachers achieved equivalent results to HCP instructors for skills, 25,[27][28][29] knowledge transfer 26,28 and confidence boost. 26Peer training has already been shown effective for teenagers in health education, especially when talking about taboo topics. 42A recent study showed that after CPR training, male teenagers were less willing to attempt resuscitation on women. 434][45] A survey of male adults reported that 34% feared sexual harassment charges. 46Issues that can hinder resuscitative efforts might be better addressed with teens by peers than by HCPs.This aspect of training should be further assessed with an appropriate study design.
As a further point, it has been shown that teenagers as peertutors who taught health education topics (e.g., healthy nutrition) applied this knowledge in their daily life. 42Likewise, peer-training by medical students has been shown to increase the tutors' own resuscitation skills, confidence and willingness to initiate CPR.Whether this also applies to schoolchildren is also still unknown.
Studies [25][26][27][28][29] included here reported heterogeneous preparatory educational strategies for peer-tutors.Peers had received education for between 3 h and 2 days, including either only knowledge and skills of CPR [26][27][28][29] or additional didactic skills such as the Peyton's four-step approach 25 or instructions on providing feedback. 25This heterogeneity between studies might explain the divergent results of the peer-taught CPR training.As one example, a study using same-aged peer-tutors reported worse skill acquisition (compared to HCPs) for some skills even after extensive training of the peertutors. 28In contrast, another study 25 intentionally selected peers who were two to three years older than their 'trainees' and achieved equivalent results compared to HCPs.However, whether older peers really achieve better results, remains to be determined by specifically designed studies.

Schoolteacher as trainers
In the studies of this review, training by schoolteachers [30][31][32][33][34][35][36] was overall equivalent [30][31][32][33][34][35][36] to HCP training.For some skills, teachers reached superior results ('calling EMS' 33 , 'compression rate 30,35 and depth 350 , 'overall judgement' 32,33 ), while ventilation skills after one year were inferior when taught by teachers 30,35 .][36] The included studies reported initial training of the schoolteachers to become CPR instructors.However, no information was available on whether these teachers were provided with refresher courses, similar to those for ERC-certified BLS instructors. 47Both initial training and refresher courses are important supportive strategies as lack of confidence in their own CPR knowledge and skills has been reported as a relevant factor for lower willingness to teach CPR in schools. 15It has been suggested to add CPR instructor training to the teacher training at universities. 12The impact of subsequent refresher courses has not yet been studied.

Medical students
Our review indicates that medical students are a good alternative to HCP instructors. 31,37,38Surprisingly, medical students showed superior results in transferring knowledge 37,38 and in the skills 'using an AED' 31 and 'overall skill assessment'. 38Previous studies have suggested that such training could be incorporated into undergraduate medical curricula considering that acting as a CPR instructor in schools improved medical students' own CPR skills. 39,48,49Involving medical students in school CPR training programmes was has also been proposed as part of a concept of creating 'training cascades', 50,51 where medical students instruct schoolteachers who then select and train schoolchildren as peer-instructors to teach their classmates.Such a system could demonstrate that essential CPR skills can be acquired by anyone.In addition, university education could be directly linked to a service for the society.However, research is still needed to better understand the effective mechanisms of such cascades.
Overall, this systematic review shows that 'Kids-Save-Lives' trainings for schoolchildren does not appear dependent on HCPs as instructors.Schoolteachers have already been proposed by ILCOR and the European Resuscitation Council as equivalent alternatives. 12,52This systematic review confirms this recommendation and even suggests that schoolteachers could be the preferred option if given proper training opportunities.For easier implementation, we encourage the inclusion of CPR instructor training into teacher training at university.Such trainings could be held by medical students.Including peer-tutors could help to reach more schoolchildren.
As a further limitation, publication bias is likely given that the investigators were interested in the topic. 53However, we did not formally assess publication bias as only a few studies could be included in the meta-analyses.Finally, the included studies were performed in Europe and two in Asia.Whether these findings can be transferred to other countries with different cultural and/or socioeconomic contexts cannot be answered with certainty.

Knowledge gaps and future research
Several open questions remain regarding teachers in 'Kids-Save-Lives' trainings.For peer-tutors, a small age gap between tutor and trainee may benefit schoolchildren, but this hypothesis requires further investigation.For both peer-tutors and schoolteachers, clearer information is needed about refresher courses, including the extent, content, and timing of such courses.Studies are also needed to evaluate combinations of peer-training and schoolteacher-led training, as well as 'training cascades' with medical students.
To allow for appropriate comparisons and meta-analyses, validated age-adapted training programmes, questionnaires, and skills-assessments need to be standardized.Therefore, uniform reporting guidelines for educational studies in resuscitation are urgently needed.

Conclusions
This systematic review analysed studies comparing different alternative training personnel (peer-tutors, schoolteachers, or medical students) with HCPs as instructors.Overall, the studies showed equivalent learning outcomes for CPR skills and knowledge up to one year, and some aspects of knowledge acquisition were even superior after training by non-HCPs.For peer training, a small age gap between peers and the trainees trained might be advisable.Based on these results, future studies should address whether involving non-HCP instructors makes these programs more costeffective and easier to integrate into school curricula, as well as examining which type of refresher courses are most effective for various non-HCP instructor groups.This would potentially increase the overall effectiveness of Kids-Save-Lives programmes.

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Fig. 2 -
Fig. 2 -Forest plot depicting size effect calculated with random-effects model for binary data (% students passing the skills test) for the outcomes compression depth (A) and compression rate (B) of the intervention group 'peertutors'.Confidence interval for homogeneity testing with Cochrane's Q-Test and for the metaanalysis was set at a = 0.05.Included references: Beck 2015 25 , Sabihah 2020 28 , Santomauro 2018 29 , Damvall 2022.27

Table 4 -
Effect direction plots depicting comparisons between the intervention and control group for A: peer-tutors, B: schoolteacher-led training and C: medical led training.,: No significant difference,*/+:significant difference.EMS = emergency services, C = compression, AED = automatic external defibrillator, V = ventilation, Vol.= volume, mths = months, yrs = years.